Gamma-glutamyltransferase and risk of cardiovascular mortality: A dose-response meta-analysis of prospective cohort studies Junna Wang1☯, Dandan Zhang2☯, Rongzhong Huang3, Xingsheng Li2*, Wenxiang Huang1*

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1 Department of Infectious Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China, 2 Department of Gerontology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China, 3 Department of Rehabilitation Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ☯ These authors contributed equally to this work. * [email protected] (XSL); [email protected] (WXH)



Citation: Wang J, Zhang D, Huang R, Li X, Huang W (2017) Gamma-glutamyltransferase and risk of cardiovascular mortality: A dose-response metaanalysis of prospective cohort studies. PLoS ONE 12(2): e0172631. doi:10.1371/journal. pone.0172631

Serum gamma-glutamyltransferase (GGT) elevation likely contributes to cardiovascular (CV) mortality, however it has remained unknown whether a dose-response relationship exists between serum GGT and CV mortality.

Editor: Yoshihiro Fukumoto, Kurume University School of Medicine, JAPAN

We searched the PubMed, EMBASE, and Cochrane library databases for prospective cohort studies published up to October 2, 2016. Summary hazard ratios (HRs) with their corresponding 95% confidence intervals (CIs) were calculated using a fixed effects model.

Received: November 22, 2016 Accepted: February 7, 2017 Published: February 23, 2017 Copyright: © 2017 Wang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: This project was supported by the Chongqing Science Foundation, China (No: KJ130332), The young elite talents project (No: 2014) in the second Affiliated Hospital of Chongqing Medical University and the research projects of Health Bureau, Chongqing, China (No:20102153). The funders play a role in decision to publish, or preparation of the manuscript.


Findings Nine prospective studies, including 527,589 participants and more than 7,011 cases, were included in this meta-analysis. For the moderate, high, and highest levels of GGT, the pooled HRs of CV mortality were 1.11 (95% CI = 1.04–1.19), 1.29 (95% CI = 1.21–1.38) and 1.59 (95% CI = 1.47–1.72), respectively (all p < 0.05 as compared to the lowest levels of GGT). Additionally, the HR per incremental increase of GGT by 10 U/L was 1.10 (95% CI = 1.08–1.11). Evidence of a positive relationship with nonlinear trend for GGT elevation with CV mortality in females was found (P = 0.04 for nonlinearity). However, a linear model was better fit to illustrate the GGT-CV mortality among males (P = 0.304 for nonlinearity).

Conclusions These findings indicate that serum GGT activity within the reference interval is positively associated with increased risk of CV mortality in a dose-response manner.

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Competing interests: The authors have declared that no competing interests exist.

Introduction Cardiovascular disease (CVD) is one of the leading causes of mortality in developed countries and responsible for an estimated 17.5 million annual deaths in the world [1], representing as much as 60% of all deaths in regions such as Eastern Europe [2]. Despite age-standardized death rates from CVDs are estimated to be steadily decreasing for decades in the world as a whole, nonetheless, population growth and aging may lead to increase the absolute burden of CVDs [3]. Therefore, early prognosis and effective primary prevention are essential to lower the burden of this fatal disease, and identification of modifiable and biological factors would be imperative in changing CV mortality throughout whole communities and populations. Serum gamma-glutamyltransferase (GGT), a commonly used marker of hepatobiliary disease and excess alcohol consumption [4,5], is a plasma membrane enzyme that can degrade the circulating antioxidant glutathione (GSH) and increase intracellular GSH synthesis by assimilating and reutilizing the precursor amino acid [6,7]. Beyond its physiological functions, a large number of epidemiological studies have emerged that link serum GGT within its reference interval to the incidence of chronic conditions and diseases, including metabolic syndrome, diabetes, hypertension, body mass index, hyperlipidemia and others [8–13]. It is not understood why serum GGT levels within the normal interval would be associated with various clinical diseases. In fact, serum GTT has been shown to have pleiotropic effects ranging from antioxidant to pro-oxidant [14]. However, the precise mechanism by which serum GGT activity is predominantly antioxidant or pro-oxidant in the context of various clinical diseases is not currently understood. Despite the mechanism being unknown, there are considerable prospective studies published reporting on the independent role of serum GGT in the pathogenesis and clinical evolution of cardiovascular diseases [15,16] and CV mortality in the general population [17–24]. However, individual studies regarding the association between serum GGT levels and increased risk of CV mortality have been inconsistent. Findings from studies of the third US National Health and Nutrition Examination Survey showed that the risk of cardiovascular mortality for persons with elevated GGT was diminished and no longer statistically significant after controlling numerous CVD risk factors among 14,950 adult participants [25]. Similarly, no significant relationships between serum GGT and CV mortality were observed in 2,724 Japanese men, for whom the prevalence of smoking and drinking is high [26]. Therefore, the predictive role of serum GGT in monitoring CV mortality is still controversial, and the evolving debate is focused on whether established cardiovascular risk factors may attribute to the increased risk of CV mortality. Previous meta-analysis described that baseline levels of GGT were associated with an increased future risk of CV and all-cause mortality [27,28], however, few of these studies established a dose-response of GGT exposure associated with the risk increase or determined the shape of dose-response curve to find whether it is a linear relation, saturation or U-shaped curve relation between GGT exposure level and CV mortality risk. Additionally, numerous new studies have been reported in recent years [21–23], therefore, it is meaningful to clarify these contradictory results between serum GGT and the risk of CV mortality and more precisely evaluate the shape of dose-response association between serum GGT and CV mortality.

Materials and methods Search strategy We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline [29] for performing and reporting corresponding results in this meta-

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Gamma-glutamyltransferase and cardiovascular mortality

analysis (S1 Appendix). We systematically searched all published articles indexed in PubMed, EMBASE and Cochrane Library before October 2, 2016 without language or time limitations. The following medical subject headings were used for searching the relevant literatures: (Gamma- glutamyltransferase OR GGT OR liver enzymes OR γ-Glutamyltransferase OR gamma-GT OR γ-GT OR nonalcoholic fatty liver disease) and (cohort OR observational OR prospective OR follow-up OR longitudinal) and (cardiovascular mortality OR cardiovascular disease OR myocardial infarction OR ischemic heart disease OR coronary artery disease OR heart diseases OR coronary disease OR mortality OR CVD OR death OR heart death OR sudden death OR cause of death OR all-cause mortality OR cardiac death OR CV death OR deaths) (S2 Appendix). Additionally, we contacted the original authors to obtain extra information if necessary, and reviewed reference lists of other relevant studies and pertinent reviews to identify works that were not found in the database search.

Eligibility criteria The included studies in the meta-analysis had to meet the following criteria: 1) have a prospective cohort design (eg, not cross-sectional design, case-control design, retrospective cohort design, literature reviews and experimental design); 2) subjects enrolled in the study at baseline were free of any pre-existing diseases, especially cardiovascular diseases in the general population; 3) the exposure of interest was serum GGT concentration and the corresponding categories were more than 2 levels; 4) the outcome of interest was CV mortality; 5) Reported adjusted HRs or relative risks (RRs) with 95% CIs at least three quantitative GGT categories, or provided the number of cases and total participants or person-years for each category of serum GGT levels; 6) the reported HRs or RRs had been adjusted at least for age and gender; 7) the duration of follow-up was more than five years.

Data extraction and validity assessment One investigator (J.N.W) extracted the data from the eligible studies, another investigator (D. D.Z) validated the data for accuracy independently with a standardized form as follows: first author’s name, publication year, country of the participants, name of study or source of participants, baseline survey period, follow-up time (year), age at recruitment (mean or range), gender (female, male or both combined), mean or median range of GGT levels in each category, the size of observational population and CV mortality cases for each GGT levels, values of HRs or RRs with their 95% CIs by quantile, and adjusted potential confounders. Additionally, if the articles presented the data separately by gender, we treated them as two independent studies and extracted the data separately. When diverse adjustments were provided, we extracted the HRs (95% CIs) with the most confounders adjusted. For studies with published data in people with and without diabetes separately, we just extracted the results in subjects without diabetes. The summary data of each identified work in our meta-analysis were presented in Table 1. The quality of included studies was assessed by the Newcastle-Ottawa Quality Assessment Scale for cohort studies [30].

Data synthesis and statistical analysis We conducted separate meta-analyses for different levels of GGT concentration categorized into four levels as in a meta-analysis of Coffee Consumption and Risk of Cardiovascular Disease [31]. We calculated the pooled risks and 95% CIs of CV mortality by the general variancebased method that requires information on the RRs or HRs and the 95% CIs for each study [32]. We separated the GGT exposure levels into four groups, including the lowest, the moderate, the high, and the highest groups. In each included study, we considered the lowest and the

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Netherlands Rotterdam


Kengne A P, 2012 [20]

Ruttmann E, 2005 [17]

Wannamethee S G,2008 [18]

PLOS ONE | DOI:10.1371/journal.pone.0172631 February 23, 2017

Breitling L P, 2011[19]

Koehler E M, 2014 [21]

Sung K C, 2015 [22]





Name of study or source of participants



2002– 2009

1990– 2009

1986– 1992

1978– 2004

1985– 2001

1994– 2009

Year of Baseline survey




















FollowAge or up (mean range ± SD) (yr) mean (yr)




Gender (female/ Male/ Both)









178/ 260260

672/ 5186

507/ 19090

1043/ 6997

1455/ 89114

1571/ 74830

317/ 9403

402/ 7866

Case/ Total


1. 1 2. 0.95 (0.78–1.16) 3. 0.94 (0.76–1.16) 4. 1.46 (1.22–1.75) 1. 1 2. 1.04 (0.82–1.32) 3. 1.29 (1.03–1.61) 4. 1.77 (1.47–2.13) 1. 1 2. 1.17 (1.02–1.33) 3. 1.28 (1.08–1.53) 4. 1.39 (1.09–1.78) 5. 1.64 (1.35–2.0) 1. 1 2. 1.04 (0.88–1.22) 3. 1.35 (1.11–1.64) 4. 1.46 (1.14–1.88) 5. 1.51 (1.21–1.89) 1. 1 2. 1.10 (0.91,1.32) 3. 1.13 (0.93,1.37) 4. 1.40 (1.16,1.70) 1. 1 2. 1.07 (0.71–1.62) 3. 1.27 (0.87–1.86) 4. 1.61 (1.11–2.35) 5. 2.02 (1.39–2.94) 1. 1 2. 1.40 (1.10,1.77) 3. 1.58 (1.24,2.01) 4. 1.47 (1.14,1.91) 5. 2.07 (1.43,2.99) 1. 1 2. 0.92 (0.50–1.70) 3. 1.21 (0.67–2.20) 4. 1.35 (0.72–2.56)

GGT Level (U/L)

1. 12 2. 18 3. 25 4. 49 1. 11 2. 17 3. 25 4. 49 1. 0.05. Abbreviation: CI, confidence interval; HR, hazard ratio. The hazard ratios were adjusted for potential confounders. doi:10.1371/journal.pone.0172631.g002

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Gamma-glutamyltransferase and cardiovascular mortality

Fig 3. Dose-response relationship between serum GGT levels and risk of CV-mortality in prospective studies. Restricted cubic splines and generalized least squares dose-response models on evaluation of association between GGT and risk of CV mortality. (A) Overall analysis; (B) females; (C) males; (D) Europe; (E) Asia. The solid line represents the fitted hazard Ratio curve compared to the subgroup with the lowest mean levels of serum GGT, and Lines with long dashes represent 95% CI of this risk by restricted cubic splines model. Lines with short dashes represent the weighted regression index compared to subgroup with lowest mean levels of serum GGT by generalized least squares model. doi:10.1371/journal.pone.0172631.g003

in turn did not significantly alter the initial relationship of GGT and CV mortality risk. These findings confirm the reliability of our results.

Publication bias analysis There was no evidence of publication bias for any association as revealed by Begg’s test and Egger’s test (all P > 0.05).

Discussion We performed a meta-analysis of the moderate, the high, and the highest levels of serum GGT compared to the lowest level of serum GGT and dose-response relationship between GGT and the incidence of CV mortality. There was evidence of a nonlinear positive dose-response relationship between GGT and CV mortality after pooling seven articles including 515,446 participants and 6,339 cases of CV mortality. Notably, a flat association was observed in the lowest range of GGT levels < 13U/L, thereafter the shape of dose-response curve was steeper with serum GGT levels 13 -< 52.5U/L. Furthermore, the increases in risk somewhat flattened at above 52.5U/L GGT. For the dose-response meta-analysis, increases of 10U/L of circulating GGT levels were associated with a 10% increase in the risk of CV mortality. Sensitivity analysis was conducted further and did not significantly alter the result. No evidence of heterogeneity or publication bias was detected across the 9 prospective articles. Compared with the lower categories, those of the moderate or highest GGT activity categories did have a significantly increased risk of CV mortality in all participants combined and in subgroups. There is an incremental increase in CV mortality of approximately 9% for males and 12% for females per 10 U/L of GGT elevation, this association seems to be stronger for females than males.

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Gamma-glutamyltransferase and cardiovascular mortality

Fig 4. The two-stage dose-response meta-analysis on serum GGT and CV mortality. The squares represent the risk estimate for each individual study, with the area reflecting the weight assigned to the study. The horizontal line across each square represents the 95% confidence interval. The diamond represents the summary risk estimate, with width representing 95% confidence interval. CI, confidence interval; HR, hazard ratio. doi:10.1371/journal.pone.0172631.g004

However, the current findings should be interpreted critically, considering that the GGT level of comparison groups was quite different. The results from the British Women’s Heart and Health Study indicated that GGT activity did not have a causal role in the incidence of coronary heart disease (CHD), independent of alcohol intake [44]. However, a prospective study in the Japanese population found that the serum GGT level was predictive of mortality from cardiovascular mortality among females for whom the prevalence of ever-drinkers was very low, but no associations were seen among males [26]. The reason for the gender difference remains unclear, and the authors suggested that the difficulty in controlling for the effects of alcohol consumption in males might partly account for the gender difference. One possible explanation for this result could be that moderate alcohol consumption reduces the risk of atherosclerosis by increasing plasma concentrations of high-density lipoprotein (HDL) cholesterol, a well-established major protective factor against CHD [45]. In addition, γ-GT is recently considered to be an oxidative stress marker. A Japan study reported that a positive correlation was observed between the circulating oxidative

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Gamma-glutamyltransferase and cardiovascular mortality

Table 2. Subgroup analyses of pooled Hazard Ratios (HRs) of CV mortality per 10 U/L increase in GGT level. Subgroup

Number of studies HR(95%CI)

P value Test for heterogenity* I2(%)

All studies

Pheterogensity Pinteraction


1.10 (1.08, 1.11) 0





1.09 (1.07, 1.10) 0





1.12 (1.09, 1.15) 0



1.09 (1.08, 1.11) 0



Gamma-glutamyltransferase and risk of cardiovascular mortality: A dose-response meta-analysis of prospective cohort studies.

Serum gamma-glutamyltransferase (GGT) elevation likely contributes to cardiovascular (CV) mortality, however it has remained unknown whether a dose-re...
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